A nurse is completing the Romberg's test on a patient. Which is the correct technique for conducting this?
Instruct the client to lie on his back and slowly slide his heel down the shin of the opposite leg, from the knee to the ankle.
Instruct the client to walk across the room on his heels and to return walking on his toes.
Have the client stand with feet together, arms at the sides. Begin with eyes open then with eyes closed. Try to maintain position for 20 seconds.
Ask the client to touch the thumb of one hand to each finger on that same hand and then repeat using the other hand.
The Correct Answer is C
Choice A reason: Heel-to-shin tests cerebellar coordination, not balance like Romberg’s. It assesses motor precision, not proprioception or vestibular function, which Romberg’s targets by checking sway with eyes closed, making this technique irrelevant to the intended assessment here.
Choice B reason: Walking on heels and toes evaluates motor strength and coordination, not stationary balance. Romberg’s tests proprioceptive stability, not gait, missing the core focus on vestibular and sensory integration critical to this neurological balance assessment fully.
Choice C reason: Romberg’s test assesses balance by having the client stand, feet together, eyes open then closed for 20 seconds. Sway with eyes closed indicates proprioceptive or vestibular issues, making this the precise, standard technique for this evaluation accurately.
Choice D reason: Finger-to-thumb tests fine motor skills and coordination, not balance. Romberg’s focuses on postural stability via sensory input, not hand dexterity, rendering this action unrelated to assessing the client’s equilibrium as intended in this context completely.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Clenching teeth tests cranial nerve V’s motor branch, innervating mastication muscles like the masseter. This assesses strength and symmetry, directly evaluating trigeminal function, making it the precise instruction for this nerve’s motor assessment accurately here.
Choice B reason: Opening the mouth and saying “ah” tests cranial nerves IX and X, not V. This assesses gag reflex and palate movement, missing the trigeminal’s role in jaw strength, rendering it irrelevant to this specific nerve exam fully.
Choice C reason: Shining light in the eye tests cranial nerves II and III, not V. This checks pupil response, unrelated to trigeminal sensory or motor functions, excluding it from the assessment of jaw and facial sensation entirely here.
Choice D reason: Closing one eye and looking tests cranial nerves III, IV, and VI, not V. This evaluates eye movement, not trigeminal innervation of facial muscles or sensation, disconnecting it from the intended cranial nerve assessment fully here.
Correct Answer is D
Explanation
Choice A reason: Syphilitic chancre is a painless ulcer, not itchy with white discharge. This STD lacks the erythematous, swollen, thick discharge presentation, excluding it from matching the client’s vaginal symptoms entirely and accurately in this case here.
Choice B reason: Trichomoniasis causes frothy, yellow-green discharge with itching, not thick white. This parasitic infection’s discharge differs from the observed curd-like consistency, making it less likely than candidiasis for this clinical picture fully here.
Choice C reason: Bacterial vaginosis produces thin, gray discharge with fishy odor, not thick white or intense itching. This bacterial imbalance contrasts with the erythematous, swollen findings, ruling it out as the suspected condition comprehensively here.
Choice D reason: Candidal vaginitis, from yeast, causes thick, white, curd-like discharge, itching, and erythema. This matches the client’s swollen labia and mucosal redness, making it the most likely diagnosis for these vaginal symptoms accurately here fully.
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